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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202625
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:23:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/06/2025 04:23 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ALEXANDRIA VICTORIA 2FACILITY NUMBER:
445202625
ADMINISTRATOR/
DIRECTOR:
GRYSPOS JR, JOHNFACILITY TYPE:
740
ADDRESS:228 MORRISSEY BLVDTELEPHONE:
(831) 429-9137
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 8CENSUS: 6DATE:
03/06/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator John Gryspos, Jr.TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Annual Continuation visit and met with Administrator John Gryspos, Jr. This annual inspection is a continuation of the annual visit that was conducted on 2/18/2025. During today's visit, there are 6 residents and 2 caregivers.

LPA reviewed 6 resident records. 5 out 6 resident records included physician's reports, needs and service plans, emergency contact information. Resident R4's physician report was incomplete. LPA advised ADM, prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice.

LPA reviewed 6 staff records. 6 out of 6 staff records included medical assessments with TB results, California fingerprint clearance, and staff training.

LPA reviewed 6 residents Centrally Stored Medication and Destruction Records (CSMDRs). 6 CSMDRs were documented accurately.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 8/8/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 2/12/2025.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. A Technical Assistance was issued, see LIC9102 for more information. An exit interview was conducted with ADM John Gryspos, Jr and a copy of this report was provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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